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ILIGAN MEDICAL CENTER COLLEGE

San Miguel Village, Pala-o, Iligan City
Tel. No. 221-4661 – Fax No. 221-6584
www.imcc.edu.ph
PACUCOA ACCREDITED

PEDIATRIC GROWTH AND DEVELOPMENT FORM

NAME: Cloa, Aune Rhea O. YEAR LEVEL: 3rd Year GROUP NO: Group 2
HOSPITAL/WARD: GTMLH INCLUSIVE DATE OF EXPOSURE:
CLINICAL INSTRUCTOR: Sir Suan RATING:
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PATIENT ASSESSMENT DATA BASE

I. GENERAL INFORMATION

Child: Rosal, Kurt Ruselle Source of Information: mother and patient’s chart
Age/Sex: 1 year old, Male Relationship to Child: mother
Birth Date: October 14, 2022 Reliability of Historian:
Address: Santiago, Iligan City Language/Dialect Spoken: Bisaya
Religion: Roman Catholic Inclusive Date of Confinement: March 29, 2024
Nationality: Filipino Discharge Date and Time:
Admission Date and Time: March 29, 2024 Final Diagnosis: PCAP-C
Chief Complaint: Cough Rank in the Family: Youngert
Initial Diagnosis: PCAP-C Insurance: None
Attending Physician: Dr. Macabalo

II. PATIENT HEALTH HISTORY

A. NATAL HISTORY (IF KNOWN)

Age of Gestation: Birth Weight: Head Circumference:
Chest Circumference: Abdominal Circumference:
Respiratory Effort: Heart Tones: Muscle Tone:
Reflex Irritability: Color: Total APGAR Score:
Type of Delivery (Please Check): Normal Spontaneous Vaginal Delivery (NSVD) Caesarian Section Forceps Delivery

B. PAST HEALTH HISTORY (Describe in a Sentence)

1. History including communicable diseases, operation, accidents, etc…
NONE
2. History of Hospitalization (Include dates, hospital/s, nature of confinement)
Pneumonia (February 6, 2024)
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3. Dental Health Status:

4. Allergies (Specify) None
5. Record of Immunization:

C.
VACCINES DATE SITE AND ROUTE DOSE REACTION/VACCINE LOT. NO. PHYSICIAN/NURSE
a. BCG
b. HEPATITIS 1
2
3
c. BOOSTER
d. DPT 1
2
3
e. BOOSTER
f. POLIO 1
2
3
g. BOOSTER
h. MEASLES
i. MMR 1
2
j. CHICKEN POX
k. HEPATITIS 1
2
l. TYPHOID FEVER
m. OTHERS
1. HAEMOPHILUS
INFLUENZA TYPE B
2. PNEUMOCCOCAL
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3. MENINGOCCOCAL
A&C
D. PRESENT ILLNESS
Describe complaint/description of illness and initial treatment: 1 week prior to admission, noted onset of cough. 1 day PTA, had one febrile episode
relieved with paracetamol 1 dose. On same day (+) productive cough. On morning PTA, onset of difficulty of breathing, hence admitted.

E. RESPONSE OF PATIENT AND CHILD TO ILLNESSS:

Parental concept of diagnosis (parent’s own words): patient has persistent cough
Role of the parents (actual performance in the case of the child): administered salbutamol syrup for cough
Any routine at home adhered as a result of child hospitalization? Second hand smoke and dusty environment
Child’s understanding of diagnosis and reason for hospitalization (patient’s own words):N/A
Fears regarding treatment: patient was afraid of any procedure that has needle
Child’s self-care (activities patient can do/perform):
F. FAMILY BACKGROUND
1. Describe community home environment: their home was surrounded by cigarette smokers and near highway (dusty air)
2. Describe cultural condition: Prays on every occasion
3. Family members (parents, sibling, grandparents) staying in the house:

NAME AGE EDUCATION OCCUPATION HEALTH CONDITION

Karren Valmonia 23 High School Housewife Healthy
Ardel Rosal 22 High School Scrapper Healthy
Mayzze Mae 3 Healthy
Kurt Ruselle Rosal 1
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4. Any caretaker? NONE Describe Caretaker:

PHYSICAL ASSESSMENT

A. MEASUREMENT
Height : 78 cm Head Circumference: 45 cm Abdominal Circumference: 42 cm
Weight: 9.8 KG Chest Circumference: 46 cm

Vital Signs: Day 1 Day 2 Day 3 Day 4 Day 5

Temperature: 35.2
Apical Pulse: 140 bpm
Respiration: 36 cpm
Blood Pressure:

B. APPEARANCE (Check if applicable)

General Appearance : / alert well nourish comfortable / responsive lethargic uncomfortable
malnourish dull gross anomalies unresponsive expressionless
Voice and Cry : strong, lusty cry weak cry low pitch cry high pitch cry stridor/hoarse cry
Odor : / none musty odor maple syrup sweaty feet acetone

C. INTEGUMENT
Pigmentation : / even pigmentation pigmented nevi large, flat back and blue over sacrum, buttocks
Color : cyanosis jaundice pallor multiple case at last spot
Lesions : / none acne erythematous macula papule
pustule petechiae cyanosis subcutaneous nodules vesicles
Consistency of Skin: / good turgor smooth & firm poor turgor dryness edema
lack of subcutaneous fats fontanel closed fontanel open
Nails : / normally pigmented good nail growth cyanosis pallor fitting of nails
broad nail beds
Hair Consistency: / no excessive breaking / consistent growth pattern dry, coarse, brittle hair alopecia
unusual hairiness tufts of hair over spine sacrum absence of pubic hair (adolescents)
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D. HEAD AND NECK

Scalp : / absence of lesion ring worm lice
Face : / symmetrical movement asymmetry twitching
Sinuses: / non-tender tender seborrheic dermatitis
Eyes (Screening of vision: Snellen’s Chart) : ability to focus and follow movement, see object placed a few feet away (younger child)
completely white
inability to follow movement or to see object placed a few feet away
Sclera : / completely white yellow blue
Eye socket: / normally placed protrusion of eyeball deeply placed eyeball
Iris : / upper and lower margins visible between the lids, at rest setting sun sign (iris appears to be beneath the lower lids)
Movement: intermittent strabismus/nystagmus in newborn fixed strabismus
involuntary repetition isolations of one or both eyes nystagmus fiexed
Eyelids: / fully cover eye/ raised on opening plosis of eyelid
Conjunctiva: / clear style inflammation hemorrhage small red transverse lines (Stimon’s Lines)
Cornea: / clear opacity inflammation redness
Discharge: tears purulent
Pupils: / round, regular, clear, equal brisk operation to light/accommodation reflex
sluggish or asymmetrical reaction to light, lack of accommodations reflex
Lens: / clear opacities
Ears: / no present sinuses small holes or pits anterior to ear
Position: top to ear above level of eye top of ear below level of eye
Discharge: / none with odor
Hearing: infant, ------ to sound/older child responds to whisper command diminished hearing in one or both ear
Nose: _/ no secretion breath through nose breath through mouth unusual shape &/or flowing of nostrils
Mouth: / intact palate teeth in good condition older child presence of permanent teeth circumcial
pallor
/ no secretion cleft palate poor teeth formation green or black teeth stained teeth
Gums: retention cysts (medium) inflamed & abnormal color drooling, pus, tenderness
Tongue: / moves freely pink with conical, piliforms --- tender papillae tremors on protrusions
Larynx: hoarseness/stridor
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Neck: tracheal deviation (R/L)

Thyroid: enlarged
Neck Motion: / _ _ full lateral & upward/downward limited movement

E. LUNGS AND THORAX ASSESSMENT

Lungs: clear breath sound (bilateral) no reaction presence of bronchi / presence of wheezes
cradles diminished breath sounds mild intercostals reaction moderate intercostals reaction
severe intercostals reaction asymmetry of diaphragmatic movements
Sputum: none / small amount of clear sputum in the morning thick tenacious with foul odor
blood tinged green sputum / yellow sputum salmon sputum rusty sputum
Breast: asymmetrical discharge masses

F. HEART ASSESSMENT

Heart Assessment: / S1 / S2 S3
Femoral Pulse: / strong weak
Edema: / none edema in what location : periorbital extremities bulging extremities
Clubbing of fingers: / none clubbing in what location :
Murmurs: / none murmurs in what grade : 1 2 3 4 dextrocardia
Cyanosis: / none circumoral peripheral

G. ABDOMINAL ASSESSMENT
Skin condition: / soft hard, rigid, tender
Peristaltic motion: / not visible visible
Shape: post bellied large protruding abdomen umbilical hernia

H. GENITO-URINARY ASSESSMENT
Female genital discharge: mucoid / no odor bleeding prior to puberty copious foul odor
Male genital: orifice on distal end of penis hypospadia/epispadia descended testes
stenosis of urethral opening covers gland completely undescended testes